{"id":255,"date":"2019-05-07T14:03:02","date_gmt":"2019-05-07T18:03:02","guid":{"rendered":"http:\/\/blogs.shu.edu\/ihope2\/?page_id=255"},"modified":"2022-04-12T13:37:49","modified_gmt":"2022-04-12T17:37:49","slug":"application-form","status":"publish","type":"page","link":"https:\/\/blogs.shu.edu\/mobilizingphysicianassistants\/application-form\/","title":{"rendered":"Application Form- Mobilizing PA"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221; column_structure=&#8221;3_5,2_5&#8243;][et_pb_column type=&#8221;3_5&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_post_title _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][\/et_pb_post_title][et_pb_text _builder_version=&#8221;4.17.0&#8243; _module_preset=&#8221;default&#8221; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243;]<\/p>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f315-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"315\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/mobilizingphysicianassistants\/wp-json\/wp\/v2\/pages\/255#wpcf7-f315-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"315\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f315-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p><label> Applicant Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ApplicantName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ApplicantName\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"Email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Phone Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PhoneNumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"PhoneNumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Mailing Address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"MailingAddress\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"MailingAddress\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><label> High School Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"HighSchoolName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"HighSchoolName\" \/><\/span> <\/label>\n<\/p>\n<p><label> Current Grade<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"CurrentGrade\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"CurrentGrade\" value=\"9\" \/><span class=\"wpcf7-list-item-label\">9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"CurrentGrade\" value=\"10\" \/><span class=\"wpcf7-list-item-label\">10<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"CurrentGrade\" value=\"11\" \/><span class=\"wpcf7-list-item-label\">11<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"CurrentGrade\" value=\"12\" \/><span class=\"wpcf7-list-item-label\">12<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Caregiver Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"CaregiverName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"CaregiverName\" \/><\/span> <\/label>\n<\/p>\n<p><label> Caregiver Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"CaregiverEmail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"CaregiverEmail\" \/><\/span> <\/label>\n<\/p>\n<p><label> Caregiver Phone Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"CaregiverPhoneNumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"CaregiverPhoneNumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Gender<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Gender\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"Gender\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"Gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"Gender\" value=\"N\/A\" \/><span class=\"wpcf7-list-item-label\">N\/A<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Ethnic Background<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-165\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-165\" value=\"African American\" \/><span class=\"wpcf7-list-item-label\">African American<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-165\" value=\"Asian or Pacific Islander\" \/><span class=\"wpcf7-list-item-label\">Asian or Pacific Islander<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-165\" value=\"Caucasian\" \/><span class=\"wpcf7-list-item-label\">Caucasian<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-165\" value=\"Hispanic or Latino\" \/><span class=\"wpcf7-list-item-label\">Hispanic or Latino<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-165\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> If Other Please Specify<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-761\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-761\" \/><\/span> <\/label>\n<\/p>\n<p><label> Do you (the applicant) have any record of disciplinary action?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-567\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-567\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-567\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Do you fulfill any of the following criteria that would qualify you under an educational and economically disadvantaged background?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-700\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-700[]\" value=\"English is not your primary language, and language is still a barrier to academic performance\" \/><span class=\"wpcf7-list-item-label\">English is not your primary language, and language is still a barrier to academic performance<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-700[]\" value=\"Eligible for free or reduced-price lunches\" \/><span class=\"wpcf7-list-item-label\">Eligible for free or reduced-price lunches<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-700[]\" value=\"Live in low-income housing\" \/><span class=\"wpcf7-list-item-label\">Live in low-income housing<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-700[]\" value=\"Come from a family with an annual income below a level based on thresholds established by the U.S. Census Bureau (see adjacent table)\" \/><span class=\"wpcf7-list-item-label\">Come from a family with an annual income below a level based on thresholds established by the U.S. Census Bureau (see adjacent table)<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Which healthcare professions are you interested in?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-210\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Athletic Training\" \/><span class=\"wpcf7-list-item-label\">Athletic Training<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Dentistry\" \/><span class=\"wpcf7-list-item-label\">Dentistry<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Medical Doctor\/Physician\" \/><span class=\"wpcf7-list-item-label\">Medical Doctor\/Physician<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Medical Management\" \/><span class=\"wpcf7-list-item-label\">Medical Management<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Nurse Practitioner\" \/><span class=\"wpcf7-list-item-label\">Nurse Practitioner<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Nursing\" \/><span class=\"wpcf7-list-item-label\">Nursing<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Occupational Therapy\" \/><span class=\"wpcf7-list-item-label\">Occupational Therapy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Pharmacy\" \/><span class=\"wpcf7-list-item-label\">Pharmacy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Physical Therapy\" \/><span class=\"wpcf7-list-item-label\">Physical Therapy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Physician Assistant\" \/><span class=\"wpcf7-list-item-label\">Physician Assistant<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Speech Language Pathology\" \/><span class=\"wpcf7-list-item-label\">Speech Language Pathology<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Undecided\" \/><span class=\"wpcf7-list-item-label\">Undecided<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> If Other Please Specify<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-738\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-738\" \/><\/span> <\/label>\n<\/p>\n<p><label> How did you hear about this program?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-731\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-731\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><strong>Please complete the media release form and parental permission slip and return them to Ms. Bergmann in room N209 with a printed copy of this application. Please make sure your name and your parent\/guardian name is included on both forms.\u00a0<\/strong>\n<\/p>\n<p><a href=\"https:\/\/blogs.shu.edu\/ihope2\/files\/2019\/05\/Clifton_Permission_Slip.pdf\" rel=\"attachment wp-att-293\">Parental Permission Slip<\/a><br \/>\n<a href=\"https:\/\/blogs.shu.edu\/ihope2\/files\/2019\/05\/MEDIA-RELEASE-FORM_SHMS-general.pdf\" rel=\"attachment wp-att-294\">Media Release Form<\/a>\n<\/p>\n<p><label> Have you participated at an outreach program at Seton Hall University in the past?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-177\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-177\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-177\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> If Yes, Please List<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-799\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-799\" \/><\/span> <\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"239\"\/><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n\/* ]]> *\/\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<p>&nbsp;<\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;]If you are interested in learning more about the healthcare program at Seton Hall University, please visit:<\/p>\n<ul>\n<li><a href=\"https:\/\/www.shu.edu\/health\/dual-degree-programs.cfm\">SHMS\/ Dual Degree Program: https:\/\/www.shu.edu\/health\/dual-degree-programs.cfm<\/a><\/li>\n<\/ul>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;2_5&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text admin_label=&#8221;Dates and benefits&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h4>Application Opens: May 15<\/h4>\n<h4>Deadline: June 21<\/h4>\n<h4>Program Timeline: October through May<\/h4>\n<p>Benefits for the students:<\/p>\n<ul>\n<li>Learn about opportunities and the PA profession.<\/li>\n<li>Receive guidance from faculty and PA students.<\/li>\n<li>Hands-on clinical and poster presentation.<\/li>\n<li>Earn a Certificate of Completion.<\/li>\n<\/ul>\n<p>Eligible Candidates:<\/p>\n<ul>\n<li>Must be a high school student, grade 9 -12 (at the start of this program).<\/li>\n<li>Must identify as African American, Asian or Pacific Islander, Hispanic or Latino, OR come from an economically or educationally disadvantaged background.<\/li>\n<li>Must complete the full required application.<\/li>\n<\/ul>\n<h3>The first 30 applicants to fully complete this application and fulfill the criteria will be considered for admission for this program.<\/h3>\n<h4>Accepted applicants will be notified by August 30th.<\/h4>\n<p>[\/et_pb_text][et_pb_code admin_label=&#8221;Income Table&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h4><!-- [et_pb_line_break_holder] -->  IRS Low-Income Thresholds<!-- [et_pb_line_break_holder] --><\/h4>\n<p><!-- [et_pb_line_break_holder] --><b>2019-2020 EOF Income Eligibility Scale with Asset Cap Calculation<\/b><!-- [et_pb_line_break_holder] --><\/p>\n<table><!-- [et_pb_line_break_holder] --><\/p>\n<thead><!-- [et_pb_line_break_holder] --><\/p>\n<tr><!-- [et_pb_line_break_holder] --><\/p>\n<th>Household Size<\/th>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<th>Gross Income Not To Exceed<\/th>\n<p><!-- [et_pb_line_break_holder] -->  <\/p>\n<th>Asset Cap Calculation*<\/th>\n<p><!-- [et_pb_line_break_holder] --><\/tr>\n<p><!-- [et_pb_line_break_holder] --><\/thead>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<tbody><!-- [et_pb_line_break_holder] --><\/p>\n<tr>\n<td>1<\/td>\n<td>$24,280<\/td>\n<td>$4,856<\/td>\n<\/tr>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<tr>\n<td>2<\/td>\n<td>$32,480<\/td>\n<td>$6,584<\/td>\n<\/tr>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<tr>\n<td>3<\/td>\n<td>$40,840<\/td>\n<td>$8,312<\/td>\n<\/tr>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<tr>\n<td>4<\/td>\n<td>$49,200<\/td>\n<td>$10,040<\/td>\n<\/tr>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<tr>\n<td>5<\/td>\n<td>$57,560<\/td>\n<td>$11,768<\/td>\n<\/tr>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<tr>\n<td>6<\/td>\n<td>$65,920<\/td>\n<td>$13,496<\/td>\n<\/tr>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<tr>\n<td>7<\/td>\n<td>$74,280<\/td>\n<td>$15,224<\/td>\n<\/tr>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<tr>\n<td>8<\/td>\n<td>$82,640<\/td>\n<td>$16,952<\/td>\n<\/tr>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<tr>\n<td>+<\/td>\n<td>Add $8,640 for each additional<\/td>\n<td>Add $1,728 for each additional<\/td>\n<\/tr>\n<p><!-- [et_pb_line_break_holder] --><\/tbody>\n<p><!-- [et_pb_line_break_holder] --><\/table>\n<p><!-- [et_pb_line_break_holder] -->* Not to exceed, based on household size for all students[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f315-o2\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"315\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/mobilizingphysicianassistants\/wp-json\/wp\/v2\/pages\/255#wpcf7-f315-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"315\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f315-o2\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p><label> Applicant Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ApplicantName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ApplicantName\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"Email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Phone Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PhoneNumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"PhoneNumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Mailing Address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"MailingAddress\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"MailingAddress\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><label> High School Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"HighSchoolName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"HighSchoolName\" \/><\/span> <\/label>\n<\/p>\n<p><label> Current Grade<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"CurrentGrade\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"CurrentGrade\" value=\"9\" \/><span class=\"wpcf7-list-item-label\">9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"CurrentGrade\" value=\"10\" \/><span class=\"wpcf7-list-item-label\">10<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"CurrentGrade\" value=\"11\" \/><span class=\"wpcf7-list-item-label\">11<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"CurrentGrade\" value=\"12\" \/><span class=\"wpcf7-list-item-label\">12<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Caregiver Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"CaregiverName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"CaregiverName\" \/><\/span> <\/label>\n<\/p>\n<p><label> Caregiver Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"CaregiverEmail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"CaregiverEmail\" \/><\/span> <\/label>\n<\/p>\n<p><label> Caregiver Phone Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"CaregiverPhoneNumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"CaregiverPhoneNumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Gender<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Gender\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"Gender\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"Gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"Gender\" value=\"N\/A\" \/><span class=\"wpcf7-list-item-label\">N\/A<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Ethnic Background<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-165\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-165\" value=\"African American\" \/><span class=\"wpcf7-list-item-label\">African American<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-165\" value=\"Asian or Pacific Islander\" \/><span class=\"wpcf7-list-item-label\">Asian or Pacific Islander<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-165\" value=\"Caucasian\" \/><span class=\"wpcf7-list-item-label\">Caucasian<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-165\" value=\"Hispanic or Latino\" \/><span class=\"wpcf7-list-item-label\">Hispanic or Latino<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-165\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> If Other Please Specify<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-761\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-761\" \/><\/span> <\/label>\n<\/p>\n<p><label> Do you (the applicant) have any record of disciplinary action?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-567\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-567\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-567\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Do you fulfill any of the following criteria that would qualify you under an educational and economically disadvantaged background?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-700\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-700[]\" value=\"English is not your primary language, and language is still a barrier to academic performance\" \/><span class=\"wpcf7-list-item-label\">English is not your primary language, and language is still a barrier to academic performance<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-700[]\" value=\"Eligible for free or reduced-price lunches\" \/><span class=\"wpcf7-list-item-label\">Eligible for free or reduced-price lunches<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-700[]\" value=\"Live in low-income housing\" \/><span class=\"wpcf7-list-item-label\">Live in low-income housing<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-700[]\" value=\"Come from a family with an annual income below a level based on thresholds established by the U.S. Census Bureau (see adjacent table)\" \/><span class=\"wpcf7-list-item-label\">Come from a family with an annual income below a level based on thresholds established by the U.S. Census Bureau (see adjacent table)<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Which healthcare professions are you interested in?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-210\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Athletic Training\" \/><span class=\"wpcf7-list-item-label\">Athletic Training<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Dentistry\" \/><span class=\"wpcf7-list-item-label\">Dentistry<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Medical Doctor\/Physician\" \/><span class=\"wpcf7-list-item-label\">Medical Doctor\/Physician<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Medical Management\" \/><span class=\"wpcf7-list-item-label\">Medical Management<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Nurse Practitioner\" \/><span class=\"wpcf7-list-item-label\">Nurse Practitioner<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Nursing\" \/><span class=\"wpcf7-list-item-label\">Nursing<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Occupational Therapy\" \/><span class=\"wpcf7-list-item-label\">Occupational Therapy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Pharmacy\" \/><span class=\"wpcf7-list-item-label\">Pharmacy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Physical Therapy\" \/><span class=\"wpcf7-list-item-label\">Physical Therapy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Physician Assistant\" \/><span class=\"wpcf7-list-item-label\">Physician Assistant<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Speech Language Pathology\" \/><span class=\"wpcf7-list-item-label\">Speech Language Pathology<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Undecided\" \/><span class=\"wpcf7-list-item-label\">Undecided<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-210[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> If Other Please Specify<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-738\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-738\" \/><\/span> <\/label>\n<\/p>\n<p><label> How did you hear about this program?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-731\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-731\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><strong>Please complete the media release form and parental permission slip and return them to Ms. Bergmann in room N209 with a printed copy of this application. Please make sure your name and your parent\/guardian name is included on both forms.\u00a0<\/strong>\n<\/p>\n<p><a href=\"https:\/\/blogs.shu.edu\/ihope2\/files\/2019\/05\/Clifton_Permission_Slip.pdf\" rel=\"attachment wp-att-293\">Parental Permission Slip<\/a><br \/>\n<a href=\"https:\/\/blogs.shu.edu\/ihope2\/files\/2019\/05\/MEDIA-RELEASE-FORM_SHMS-general.pdf\" rel=\"attachment wp-att-294\">Media Release Form<\/a>\n<\/p>\n<p><label> Have you participated at an outreach program at Seton Hall University in the past?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-177\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-177\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-177\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> If Yes, Please List<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-799\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-799\" \/><\/span> <\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_2\" name=\"_wpcf7_ak_js\" value=\"54\"\/><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\ndocument.getElementById( \"ak_js_2\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n\/* ]]> *\/\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n &nbsp;If you are interested in learning more about the healthcare program at Seton Hall University, please visit: SHMS\/ Dual Degree Program: https:\/\/www.shu.edu\/health\/dual-degree-programs.cfm Application Opens: May 15 Deadline: June 21 Program Timeline: October through May Benefits for the students: Learn about opportunities and the PA profession. Receive guidance from faculty and PA [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-255","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/blogs.shu.edu\/mobilizingphysicianassistants\/wp-json\/wp\/v2\/pages\/255","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.shu.edu\/mobilizingphysicianassistants\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/blogs.shu.edu\/mobilizingphysicianassistants\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.shu.edu\/mobilizingphysicianassistants\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.shu.edu\/mobilizingphysicianassistants\/wp-json\/wp\/v2\/comments?post=255"}],"version-history":[{"count":4,"href":"https:\/\/blogs.shu.edu\/mobilizingphysicianassistants\/wp-json\/wp\/v2\/pages\/255\/revisions"}],"predecessor-version":[{"id":318,"href":"https:\/\/blogs.shu.edu\/mobilizingphysicianassistants\/wp-json\/wp\/v2\/pages\/255\/revisions\/318"}],"wp:attachment":[{"href":"https:\/\/blogs.shu.edu\/mobilizingphysicianassistants\/wp-json\/wp\/v2\/media?parent=255"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}